Essential Health Benefits: A little changed, a lot to monitor

  ·  Health Policy Hub   ·   Eva Marie Stahl

Last week, the Department of Health and Human Services (HHS) released the final rule for Essential Health Benefits, Actuarial Value, and Accreditation. This anticipated rule was largely unchanged from its original form. There were some small technical tweaks across a variety of areas including substance use disorder (SUD)/mental health (MH), pediatric dental and prescription drug benefits.

In her blog, colleague Sabrina Corlette of Georgetown’s Center for Health Insurance Research, nicely summarizes the rule and key changes. For our work, there are a handful of changes that deserve notice.

First, there is a resounding emphasis in support of parity for SUD/MH benefits. This is a huge win for Community Catalyst and our advocate partners. The rule’s emphasis on SUD/MH parity legitimizes these benefits as health care, not sideline conditions. These provisions are far reaching: 62 million Americans will have either new coverage for SUD/MH or improved, parity-compliant coverage when the law is implemented next year.

A second change is in the pediatric dental benefit. Many may not be fully aware of the challenges of incorporating this benefit into the EHB package, but it has continued to face hurdles related to affordability and take-up. The final rule allows a separate out-of-pocket (OOP) maximum for stand-alone dental plans. While the EHB must include a dental benefit, there is no requirement to purchase the coverage. Both raise concerns about affordability. If you would like to learn more about the dental benefit in EHB, please see the resources provided by our partner, the Children’s Dental Health Project (CDHP).

On the prescription drug front, the rule codifies that the drug benefit must include a drug in every category and class in the US Pharmacopeia’s (USP) guidelines. So states must adopt the benchmark plan’s benefit or supplement the benefit to meet this standard. Additional drugs can be added to the EHB without the penalty of added cost to states. In other words, adding drugs is not equated with adding benefits. While it’s helpful that adding drugs to EHB does not increase the cost to states, many advocates continue to be concerned about access to needed prescriptions. This will be important area to watch.

A final area to note that affects many constituencies is that of habilitative care. Toward the end of the rule, there is a table that lists the selected benchmark plans and whether or not habilitative care is defined by the state. If not (and there are many), this determination will be left to the insurer. It is disappointing that more states did not opt to define habilitative care. This will be something advocates want to pay close attention to—the habilitative care benefit will affect many vulnerable populations such as kids, people with disabilities, people with long term care needs, and people with substance use disorders.

It is important to note that the EHB package is not permanent. Rather it’s a starting approach that will be tested in 2014 and 2015. At that point, ideally, HHS will take a second look at the benchmark approach and recommended needed changes for 2016 and beyond.

These new plans exit the starting gate October 1 for open enrollment, and will rely on new technology systems, new insurance plans and new demands on its inter-agency collaboration both at the state and federal level. Many Americans will access health insurance coverage for the first time. Understandably, there will be trip ups and challenges along the way as we attempt to get systems and stakeholders to communicate. A lot of energy will be directed toward the actual implementation of the ACA.

As advocates, we are concerned about operationalizing coverage but also about whether that coverage is working for consumers. This is where monitoring will play a central role in our work moving forward. SUD/MH parity serves as an important example. Parity has been enforceable for more than three years, having passed prior to the ACA, yet violations abound in every state. The law for coverage is on the side of consumers, but how will it work on the ground?

So what does monitoring look like? How do we prepare for our monitoring role? How do we communicate our findings? These are the questions we are going to tackle in the coming months. Stay tuned for a toolkit and other resources.